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WaPo’s Ezra Klein and Sarah Kliff have written an extensive report on Obamacare implementation, which Ezra then usefully summarized at Wonkblog.

You can and should read it all yourself, but my big takeaway from the Klein-Kliff dive into the murkiest policy and political topic in the country is that how the Affordable Care Act is implemented and perceived depends very heavily on where you live. Here’s how Ezra puts it in several segments of his summary:

It’s always worth remembering that everyone in Washington is really weird. Most of the country doesn’t care much about Obamacare. They don’t have particularly strong feelings about it. And they’re never going to come into contact with something called “Obamacare,’ anyway.

In California, it’s called “Covered California.” In Connecticut, it’s “Health Access CT.” In Washington, it’s “WA State HealthPlanFinder.” People signing up for Medicaid will be signing up for the program called Medicaid. People in Washington experience Obamacare as a political abstraction and project that onto the country. That act of projection might be a huge mistake….

Different states will have wildly different experiences. California accepted the Medicaid expansion, chose to build its own exchange, is spending state money to promote the law, and is generally doing everything in its power to make Obamacare work. Texas rejected the Medicaid expansion, left the exchange to the feds, and the state’s key politicians are out there talking down the law. It’s very possible Obamacare will be a success in states like California and a failure in states like Texas. How the politics of that shake out is anyone’s guess….

And then there’s my favorite topic, the “wingnut hole” or coverage gap affecting those with incomes under the poverty line in states with skimpy Medicaid programs:

No one knows quite what to do in states that aren’t expanding Medicaid. In those states, the poorest residents will get no help but slightly less-poor residents will get lots of help. That’s confusing for everyone involved — and a real challenge to the people trying to sign folks up for the law. How do you tell someone they’re too poor to be eligible for subsidies?

Nor is anyone really certain what will happen to the hospital systems in those states, as they’re losing out on a lot of money they were counting on. The administration’s theory is that if the law is seen as relatively successful, the economics of participating in the Medicaid expansion are so overwhelmingly favorable to the states that they’ll fall in line. But no one really knows what’ll happen in that first year or two, nor who will be blamed for the resulting mess.

Quite obviously, Democrats will be eager to accentuate the positive as the Affordable Care Act is implemented, while every problem, even if it’s created by state-level Republicans fighting to sabotage the law, will be treated as a disaster by the GOP. What Klein and Kliff are warning us is that perceptions of how the new “system” is working will be obscured by the fog of political warfare, perhaps for a long time to come.

Ed Kilgore
is a contributing writer to the Washington Monthly. He is managing editor for The Democratic Strategist and a senior fellow at the Progressive Policy Institute. Find him on Twitter: @ed_kilgore.

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